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Findlay MC, Bounajem MT, Kim RB, Henson JC, Azab MA, Cutler CB, Khan M, Brandon C, Budohoski KP, Rennert RC, Couldwell WT. Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use? Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01154. [PMID: 38690880 DOI: 10.1227/ons.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era. METHODS This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis. RESULTS Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction. CONCLUSION These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.
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Affiliation(s)
| | - Michael T Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - J Curran Henson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mohammed A Azab
- Biomedical Sciences, Boise State University, Boise, Idaho, USA
| | - Christopher B Cutler
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Majid Khan
- School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Cameron Brandon
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Drexler R, Sauvigny T, Pantel TF, Ricklefs FL, Catapano JS, Wanebo JE, Lawton MT, Sanchin A, Hecht N, Vajkoczy P, Raygor K, Tonetti D, Abla A, El Naamani K, Tjoumakaris SI, Jabbour P, Jankowitz BT, Salem MM, Burkhardt JK, Wagner A, Wostrack M, Gempt J, Meyer B, Gaub M, Mascitelli JR, Dodier P, Bavinzski G, Roessler K, Stroh N, Gmeiner M, Gruber A, Figueiredo EG, da Silva Coelho ACS, Bervitskiy AV, Anisimov ED, Rzaev JA, Krenzlin H, Keric N, Ringel F, Park D, Kim MC, Marcati E, Cenzato M, Westphal M, Dührsen L. Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases. Neurosurgery 2024; 94:369-378. [PMID: 37732745 PMCID: PMC10766286 DOI: 10.1227/neu.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F. Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aminaa Sanchin
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian T. Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed M. Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Michael Gaub
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R. Mascitelli
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Eberval G. Figueiredo
- Division of Neurological Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Harald Krenzlin
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Dougho Park
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Eleonora Marcati
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lepsveridze L, Semenov M, Stepanyan G, Abudeev S. Burr Hole Microsurgery for Middle Cerebral Artery Aneurysms: A Clinical Case Series. NEUROSURGERY OPEN 2022. [DOI: 10.1227/neuopn.0000000000000001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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4
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Surgical clipping compared to endovascular coiling of ruptured coil able middle cerebral aneurysms: A single-center experience. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Randhawa HS, Pearce G, Hepton R, Wong J, Zidane IF, Ma X. An investigation into the design of a device to treat haemorrhagic stroke. Proc Inst Mech Eng H 2019; 234:323-336. [PMID: 31774350 PMCID: PMC7132436 DOI: 10.1177/0954411919890698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, we present the design considerations of a device to assist in the
potential treatment of hemorrhagic stroke with the aim of stopping blood from
flowing out into brain tissue. We present and model three designs for the
clinical scenarios when saccular aneurysms rupture in the middle cerebral artery
in the brain. We evaluate and model these three designs using computer aided
design software, SolidWorks, which allows the devices to be tested using finite
element analysis and also enables us to justify that the materials chosen were
suitable for potential use. Computational fluid dynamics modelling were used to
demonstrate and analyse the flow of blood through the artery under conditions of
normal and ruptured states. We conclude that our device could potentially be
useful in the treatment of hemorrhagic stroke, and the modelling process is
useful in assisting in determining the performance of our devices.
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Affiliation(s)
| | - Gillian Pearce
- School of Engineering and Applied Science, Aston University, Birmingham, UK
| | - Rachel Hepton
- The School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Julian Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Iham F Zidane
- Mechanical Engineering Department, College of Engineering and Technology, Arab Academy for Science, Technology and Maritime Transport (AASTMT), Alexandria, Egypt
| | - Xianghong Ma
- School of Engineering and Applied Science, Aston University, Birmingham, UK
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6
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Aneurysmal Subarachnoid Hemorrhage Associated with Small Aneurysms in Smokers and Women: A Retrospective Analysis. World Neurosurg X 2019; 4:100038. [PMID: 31360917 PMCID: PMC6610703 DOI: 10.1016/j.wnsx.2019.100038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/13/2019] [Indexed: 11/20/2022] Open
Abstract
Background Previous studies have shown low rupture rates for small aneurysms (<10 mm), suggesting that the risk of treatment could exceed the benefits. However, evidence has changed, showing crescent rates of aneurysmal subarachnoid hemorrhage (aSAH) associated with small aneurysms. We report trends in size, localization, clinical characteristics, and outcomes of intracranial aneurysms (IAs). Methods In this retrospective study, a total of 200 clinical histories of patients diagnosed with IAs over an 8-year period were analyzed. Variables considered included age, sex, tobacco consumption, morphological characteristics of the aneurysm, complications, vasospasm, and mortality. Qualitative variables were assessed by measurements of absolute and relative frequency. Smoking behavior, aneurysm size, and aneurysm rupture (AR) were compared using 1-way analysis of variance. Categorical variables were analyzed using Pearson's χ2 test. Results The average age at presentation was 58 years. The average size of ruptured aneurysms in the general group was 2.5–7.5 mm, and AR was most common in women (76%) and in patients age 50–60 years (33%). The rate of vasospasm was 19%, and mortality was 37%. Smokers composed 32% of the cohort. Heavy smokers had a 57% rate of aSAH, with an average size of rupture of 5 mm. The most common location of aneurysms and AR was the AComA (33%). Conclusions Our results suggest increasing AR rates in aneurysms smaller than 10 mm. This trend is seen especially in individuals with heavy tobacco consumption and in women of perimenopausal age. Our findings show a tendency of AR in accordance with previous results and are expected to serve as basis for further research on aneurysm management.
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Dellaretti M, Ronconi D, Batista DM, Ferreira de Souza R, Almeida CERD, Fontoura RR, Antunes PRB, Quadros RS. Safety and Efficacy of Surgical Treatment of Intracranial Aneurysms: The Experience of a Single Brazilian Center. World Neurosurg 2018; 117:e580-e587. [PMID: 29935315 DOI: 10.1016/j.wneu.2018.06.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of microsurgery for aneurysm clipping has decreased considerably in recent years. This study was conducted to demonstrate the safety and effectiveness of surgical treatment of intracranial aneurysms even in less-developed countries. METHODS This study was a retrospective review of the medical records of 320 patients with 416 aneurysms treated with microsurgical clipping at a single neurosurgical center in Brazil between 2008 and 2016. We evaluated postoperative outcomes using the modified Rankin Scale (mRS) at the time of hospital discharge, treatment efficacy by digital subtraction angiography (DSA) performed postoperatively, and mortality. RESULTS The 320 patients with aneurysms included 228 patients with ruptured aneurysms and 92 with unruptured aneurysms. Overall, 81 (26.3%) had a poor outcome (mRS score >2), and the other 227 (73.4%) had a good outcome. The presence of a ruptured aneurysm was a statistically significant factor for poor outcome (P < 0.001) and mortality (P < 0.015). Giant and large aneurysms were also associated with poor outcome (P = 0.004). When analyzed separately, unruptured aneurysms with poor outcome were only associated with aneurysm size. Among the patients with ruptured aneurysms, those with Hunt and Hess (HH) grade >2 on hospital admission had unfavorable outcomes (P < 0.0001). Among the patients who underwent postoperative DSA, 207 (89.8%) had complete aneurysm occlusion and 24 (10.2%) had residual aneurysms, with reoperation required in 8 cases. CONCLUSIONS Microsurgical treatment of intracranial aneurysms is an effective and safe method.
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Affiliation(s)
- Marcos Dellaretti
- Department of Neurosurgery, Santa Casa de Belo Horizonte Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Ronconi
- Department of Neurosurgery, Santa Casa de Belo Horizonte Hospital, Belo Horizonte, Minas Gerais, Brazil.
| | - Danilo Malta Batista
- Department of Neurosurgery, Santa Casa de Belo Horizonte Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Renata Ferreira de Souza
- Department of Neurosurgery, Santa Casa de Belo Horizonte Hospital, Belo Horizonte, Minas Gerais, Brazil
| | | | - Renato Rinco Fontoura
- Department of Neurosurgery, Santa Casa de Belo Horizonte Hospital, Belo Horizonte, Minas Gerais, Brazil
| | | | - Ricardo Sousa Quadros
- Department of Neurosurgery, Santa Casa de Belo Horizonte Hospital, Belo Horizonte, Minas Gerais, Brazil
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8
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Matsukawa H, Kamiyama H, Tsuboi T, Noda K, Ota N, Miyata S, Miyazaki T, Kinoshita Y, Saito N, Takahashi O, Takeda R, Tokuda S, Tanikawa R. Subarachnoid hemorrhage after surgical treatment of unruptured intracranial aneurysms. J Neurosurg 2017; 129:490-497. [PMID: 29076778 DOI: 10.3171/2017.3.jns162984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Only a few previous studies have investigated subarachnoid hemorrhage (SAH) after surgical treatment in patients with unruptured intracranial aneurysms (UIAs). Given the improvement in long-term outcomes of embolization, more extensive data are needed concerning the true rupture rates after microsurgery in order to provide reliable information for treatment decisions. The purpose of this study was to investigate the incidence of and risk factors for postoperative SAH in patients with surgically treated UIAs. METHODS Data from 702 consecutive patients harboring 852 surgically treated UIAs were evaluated. Surgical treatments included neck clipping (complete or incomplete), coating/wrapping, trapping, proximal occlusion, and bypass surgery. Clippable UIAs were defined as UIAs treated by complete neck clipping. The annual incidence of postoperative SAH and risk factors for SAH were studied using Kaplan-Meier survival analysis and Cox proportional hazards regression models. RESULTS The patients' median age was 64 years (interquartile range [IQR] 56-71 years). Of 852 UIAs, 767 were clippable and 85 were not. The mean duration of follow-up was 731 days (SD 380 days). During 1708 aneurysm years, there were 4 episodes of SAH, giving an overall average annual incidence rate of 0.23% (95% CI 0.12%-0.59%) and an average annual incidence rate of 0.065% (95% CI 0.0017%-0.37%) for clippable UIAs (1 episode of SAH, 1552 aneurysm-years). Basilar artery location (adjusted hazard ratio [HR] 23, 95% CI 2.0-255, p = 0.0012) and unclippable UIA status (adjusted HR 15, 95% CI 1.1-215, p = 0.046) were significantly related to postoperative SAH. An excellent outcome (modified Rankin Scale score of 0 or 1) was achieved in 816 (95.7%) of 852 cases overall and in 748 (98%) of 767 clippable UIAs at 12 months. CONCLUSIONS In this large case series, microsurgical treatment of UIAs was found to be safe and effective. Aneurysm location and unclippable morphologies were related to postoperative SAH in patients with surgically treated UIAs.
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Affiliation(s)
- Hidetoshi Matsukawa
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Hiroyasu Kamiyama
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Toshiyuki Tsuboi
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Kosumo Noda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Nakao Ota
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Shiro Miyata
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Takanori Miyazaki
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Yu Kinoshita
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Norihiro Saito
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Osamu Takahashi
- 2Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Rihee Takeda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Sadahisa Tokuda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Rokuya Tanikawa
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
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Brown MA, Guandique CF, Parish J, McMillan AC, Lehnert S, Mansour N, Tu M, Bohnstedt BN, Payner TD, Leipzig TJ, DeNardo AJ, Scott JA, Cohen-Gadol AA. Long-term follow-up analysis of microsurgical clip ligation and endovascular coil embolization for dorsal wall blister aneurysms of the internal carotid artery. J Clin Neurosci 2017; 39:72-77. [DOI: 10.1016/j.jocn.2016.12.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/26/2016] [Indexed: 11/16/2022]
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10
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Brown MA, Parish J, Guandique CF, Payner TD, Horner T, Leipzig T, Rupani KV, Kim R, Bohnstedt BN, Cohen-Gadol AA. A long-term study of durability and risk factors for aneurysm recurrence after microsurgical clip ligation. J Neurosurg 2017; 126:819-824. [DOI: 10.3171/2016.2.jns152059] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
With the recent evolution of endovascular therapies, objective evaluation of the efficacy of clip ligation for cerebral aneurysms should be performed. This study was undertaken to evaluate the durability of microsurgical clip ligation, identify risk factors for recurrence, and assess the need for long-term follow-up imaging.
METHODS
A retrospective review of medical records identified 616 consecutive patients (156 male and 460 female patients; mean age 48.4 ± 12.4 years; range 6–90 years) who underwent microsurgical clip ligation and follow-up imaging at least 1 year after discharge between 1990 and 2010 at our institution. Of a total of 926 aneurysms in 616 patients, 758 aneurysms were microsurgically clip-ligated. At presentation, 431 of these aneurysms were ruptured and 327 aneurysms were unruptured. All patients underwent postoperative baseline imaging within the 1st month of their operation. A logistic regression analysis was performed to identify which variables are more likely to predict recurrence.
RESULTS
Late follow-up angiographic imaging was obtained at a mean of 7.2 ± 4.7 years postdischarge (median 5.7 years; range 1–23 years). Of the 699 clipped aneurysms without residua, late follow-up angiography revealed only 1 (0.14%) recurrent aneurysm. Of the 59 residual aneurysms that remained after initial clip ligation on early postoperative imaging, 8 (13.6%) demonstrated growth. All of these aneurysms required treatment. None of the recurrences were due to broken or delayed displacement of clips. A total of 111 patients presented with multiple aneurysms. De novo aneurysm formation occurred in 8 (0.97%) patients, all of whom initially presented with multiple aneurysms.
CONCLUSIONS
This study provides additional evidence to support the long-term efficacy of aneurysm clip ligation. The chance of aneurysm recurrence after complete clip ligation is very small. However, there is a regrowth risk of 1.83% per year for aneurysm remnants after incomplete clip ligation. These findings support the necessity for continued followup, late angiographic imaging, and the potential need for further intervention of incompletely ligated aneurysms. Furthermore, completely clip-ligated aneurysms may not require additional surveillance imaging unless multiple aneurysms were evident at presentation.
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Affiliation(s)
- Mason A. Brown
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Jonathan Parish
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Cristian F. Guandique
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Troy D. Payner
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Terry Horner
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Thomas Leipzig
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Karishma V. Rupani
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Richard Kim
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
| | - Bradley N. Bohnstedt
- 2Department of Neurosurgery, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma
| | - Aaron A. Cohen-Gadol
- 1Goodman Campbell Brain and Spine, and Department of Neurosurgery, Indiana University, Indianapolis, Indiana; and
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Shah SS, Gersey ZC, Nuh M, Ghonim HT, Elhammady MS, Peterson EC. Microsurgical versus endovascular interventions for blood-blister aneurysms of the internal carotid artery: systematic review of literature and meta-analysis on safety and efficacy. J Neurosurg 2017; 127:1361-1373. [PMID: 28298019 DOI: 10.3171/2016.9.jns161526] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) have a poor natural history associated with high morbidity and mortality. Currently, both surgical and endovascular techniques are employed to treat BBAs; thus, the authors sought to perform a meta-analysis to compare the efficacy and safety of these approaches. METHODS A literature search of PubMed, MEDLINE, and Google Scholar online databases was performed to include pertinent English-language studies from 2005 to 2015 that discussed the efficacy and safety of either surgical or endovascular therapies to treat BBAs. RESULTS Thirty-six papers describing 256 patients with BBAs treated endovascularly (122 procedures) or surgically (139 procedures) were examined for data related to therapeutic efficacy and safety. Pooled analysis of 9 papers demonstrated immediate and late (mean 20.9 months) aneurysm occlusion rates of 88.9% (95% CI 77.6%-94.8%) and 88.4% (95% CI 76.7%-94.6%), respectively, in surgically treated patients. Pooled analysis of 12 papers revealed immediate and late aneurysm obliteration rates of 63.9% (95% CI 52.3%-74.1%) and 75.9% (95% CI 65.9%-83.7%), respectively, in endovascularly treated aneurysms. Procedure-related complications and overall poor neurological outcomes were slightly greater in the surgically treated cases than in the endovascularly treated cases (27.8% [95% CI 19.6%-37.8%] vs 26.2% [95% CI 18.4%-35.8%]), indicating that endovascular therapy may provide better outcomes. CONCLUSIONS Blood-blister aneurysms are rare, challenging lesions with a poor prognosis. Although surgical management potentially offers superior aneurysm obliteration rates immediately after treatment and at the long-term follow-up, endovascular therapy may have a better safety profile and provide better functional outcomes than surgery. A registry of patients treated for BBAs may be warranted to better document the natural course of the disease as well as treatment outcomes.
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Aneurysm Clip Compression Technique in the Surgery of Aneurysms with Hard/Calcified Neck. World Neurosurg 2015; 84:688-96. [DOI: 10.1016/j.wneu.2015.04.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 11/24/2022]
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Smith TR, Cote DJ, Dasenbrock HH, Hamade YJ, Zammar SG, El Tecle NE, Batjer HH, Bendok BR. Comparison of the Efficacy and Safety of Endovascular Coiling Versus Microsurgical Clipping for Unruptured Middle Cerebral Artery Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2015; 84:942-53. [PMID: 26093360 DOI: 10.1016/j.wneu.2015.05.073] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/15/2015] [Accepted: 05/16/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Middle cerebral artery aneurysms (MCAAs) are regularly treated by both microsurgical clipping and endovascular coiling. We performed a systematic meta-analysis to compare the safety and efficacy of these 2 methods. METHODS Literature was reviewed for all studies reporting angiographic occlusion and/or functional outcomes in adults with unruptured MCAA treated by endovascular coiling or microsurgical clipping. All studies in English that reported results for adults (≥18 years) with unruptured MCAAs, from 1990 to 2011 were considered for inclusion. RESULTS Twenty-six studies involving 2295 aneurysms treated with clipping or coiling for unruptured MCAAs were included for analysis. There were 1530 aneurysms that were treated with clipping and 765 aneurysms treated with coiling. Pooled analysis revealed failure of aneurysmal occlusion in 3.0% (95% confidence interval [CI] 1.2%-7.4%) of clipped cases. Pooled analysis of 15 studies (606 aneurysms) involving coiling and occlusion revealed lack of occlusion rates of 47.7% (95% CI 43.6%-51.8%) with the fixed-effects model and 48.2% (95% CI 39.0%-57.4%) with the random-effects model. Thirteen studies examined neurological outcomes after clipping and were pooled for analysis. Both fixed-effect and random-effect models revealed unfavorable outcomes in 2.1% (95% CI 1.3%-3.3%) of patients. There were 17 studies evaluating potential unfavorable neurological outcomes after coiling that were pooled for analysis. Fixed-effect and random-effect models revealed unfavorable outcomes in 6.5% (95% CI 4.5%-9.3%) and 4.9% (95% CI 3.0%-8.1%) of patients, respectively. CONCLUSIONS Based on this systematic review and meta-analysis of unruptured MCAAs, after careful consideration of patient, aneurysmal, and treatment center factors, we recommend surgical clipping for unruptured MCAA.
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Affiliation(s)
- Timothy R Smith
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - David J Cote
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hormuzdiyar H Dasenbrock
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Youssef J Hamade
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Samer G Zammar
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Najib E El Tecle
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - H Hunt Batjer
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Taheri Z, Harirchian MH, Ghanaati H, Khoshnevisan A, Salamati P, Miri M, Firouznia K, Saeednejad M, Shakiba M, Rahimi-Movaghar V. Comparison of endovascular coiling and surgical clipping for the treatment of intracranial aneurysms: A prospective study. IRANIAN JOURNAL OF NEUROLOGY 2015; 14:22-8. [PMID: 25874053 PMCID: PMC4395803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 08/03/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Management of intracranial aneurysms has made debates about the best treatment modality in recent years. The aim of this study was to compare the interventional outcomes between two groups of patients, one treated with endovascular coiling and the other treated with surgical clipping. METHODS This prospective study included 48 patients with intracranial aneurysms who underwent endovascular coiling (27 patients) or surgical clipping (21 patients) from July 2011 to August 2013. A neurologist examined patients in admission and followed them by phone call 1-year after intervention. RESULTS Mean modified Rankin Scale (MRS) score at the time of admission in endovascular group was 2.86 ± 0.974 whereas it was 3.81 ± 1.078 in surgical clipping group (P = 0.0040). Focal neurologic signs were higher in clipping during procedures (P = 0.0310). Of 37 patients who followed up for a year, 19 were in endovascular group and 18 in surgical clipping group. At 1 year follow-up, MRS improvement was statistically significant in coiling group (P = 0.0090), but not in clipping group (P = 0.8750). Mean difference of MRS score at the time of admission and at one year later, was 0.947 ± 1.224 in endovascular group and 0.111 ± 2.083 in surgical group (P = 0.3000). CONCLUSION There was no statistically significant difference at 1 year outcome between two groups. We recommend further interventional studies with larger sample sizes for better evaluation of the modalities.
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Affiliation(s)
- Zeinab Taheri
- Department of Neurology, Iranian Center of Neurological Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hosein Harirchian
- Department of Neurology, Iranian Center of Neurological Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Ghanaati
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshnevisan
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Salamati
- Department of Community Medicine, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Miri
- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kavous Firouznia
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Saeednejad
- Department of Radiology, Islamic Azad University, Tehran Medical Branch, Tehran, Iran
| | - Madjid Shakiba
- Department of Radiology, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Lee JY, Kwon BJ, Cho YD, Kang HS, Han MH. Reappraisal of anatomic outcome scales of coiled intracranial aneurysms in the prediction of recanalization. J Korean Neurosurg Soc 2013; 53:342-8. [PMID: 24003368 PMCID: PMC3756126 DOI: 10.3340/jkns.2013.53.6.342] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 04/05/2013] [Accepted: 06/19/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Several scales are currently used to assess occlusion rates of coiled cerebral aneurysms. This study compared these scales as predictors of recanalization. Methods Clinical data of 827 patients harboring 901 aneurysms treated by coiling were retrospectively reviewed. Occlusion rates were assessed using angiographic grading scale (AGS), two-dimensional percent occlusion (2DPO), and volumetric packing density (vPD). Every scale had 3 categories. Followed patients were dichotomized into either presence or absence of recanalization. Kaplan-Meier analysis was conducted, and Cox proportional hazards analysis was performed to identify surviving probabilities of recanalization. Lastly, the predictive accuracies of three different scales were measured via Harrell's C index. Results The cumulative risk of recanalization was 7% at 12-month, 10% at 24-month, and 13% at 36-month of postembolization, and significantly higher for the second and third categories of every scale (p<0.001). Multivariate-adjusted hazard ratios (HRs) of the second and third categories as compared with the first category of AGS (HR : 3.95 and 4.15, p=0.004 and 0.001) and 2DPO (HR : 4.87 and 3.12, p<0.001 and 0.01) were similar. For vPD, there was no association between occlusion rates and recanalization. The validated and optimism-adjusted C-indices were 0.50 [confidence (CI) : -1.09-2.09], 0.47 (CI : -1.10-2.09) and 0.44 (CI : -1.10-2.08) for AGS, 2DPO, and vPD, respectively. Conclusion Total occlusion should be reasonably tried in coiling to maximize the benefit of the treatment. AGS may be the best to predict recanalization, whereas vPD should not be used alone.
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Affiliation(s)
- Jong Young Lee
- Department of Neurosurgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Ishikawa T. What is the role of clipping surgery for ruptured cerebral aneurysms in the endovascular era? A review of recent technical advances and problems to be solved. Neurol Med Chir (Tokyo) 2013; 50:800-8. [PMID: 20885114 DOI: 10.2176/nmc.50.800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Craniotomy and clipping have been robust treatments for ruptured cerebral aneurysm for more than 50 years, with satisfactory overall outcomes. Technical advances, such as developments in microsurgical tools and equipment, adjunctive therapy, and novel monitoring methods enable safer and more efficient treatment. However, overall surgical results have not shown any major improvements, as outcomes are mainly determined by the damage from initial bleeding, and new treatment strategies are not always free from associated complications and problems. Recent advances in endovascular treatment are shifting the treatment for ruptured cerebral aneurysm from craniotomy and clipping to intravascular coil embolization. However, craniotomy and clipping are very important for the treatment of ruptured cerebral aneurysm. This paper discusses recent advances and future perspectives in the field of clipping surgery for ruptured aneurysms.
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Affiliation(s)
- Tatsuya Ishikawa
- Department of Neurological Surgery, Research Institute for Brain and Blood Vessels-Akita, 6-10 Senshu-Kubota-machi, Akita, Japan.
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Barrow DL. Intraoperative Misadventures: Complication Avoidance and Management in Aneurysm Surgery. Neurosurgery 2011; 58:93-109. [DOI: 10.1227/neu.0b013e3182275574] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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